Cholangiocarcinoma and

your Diet

Liza Strydom

Senior Specialist Dietitian

Princess Grace Hospital

HCA Healthcare UK

Introduction

• Disease and/or treatment can affect appetite and enjoyment of food.

• Nutritional recommendations for people with cancer can be very confusing.

• Emphasis around building up and maintaining your strength. This will help manage the effect

of cancer and it’s treatment on the body.

Eating a balanced diet will help you to:

• 1. start treatment with reserves

• 2. prevent body tissues from breaking down

• 3. rebuild tissues more easily

• 4. maintain defenses against infection.

• Nutrition in Cholangiocarcinoma is based around managing symptoms from the disease

and/or the treatment you receive eg., chemo/surgery.

The Eat Well Plate

Treatment options for Cholangiocarcinoma

• Surgery

• Chemotherapy

• Radiotherapy

Surgery

• Removal of bile ducts

• Partial liver resection

• Whipple procedure

• Surgery to relieve obstruction (blockage)

• Liver transplantation (USA only)

• Stent insertion

Whipples Procedure

What is a Whipples procedure?

• Also known as a pancreaticoduodenectomy

• Removal of the head of the pancreas, a portion of the bile duct, gallbladder and the

duodenum, usually with part of the stomach.

What does the pancreas do?

• Large gland that lies at the back of the upper abdomen. It has two main functions:

• Produces digestive enzymes: pancreatic juice and bile mix with food in the intestine to

digest food into nutrients used by the body.

• Produces hormones: such as insulin, which controls the level of sugar in the blood.

Considerations following Surgery

• Delayed gastric emptying- stomach takes longer than normal to empty- can

cause nausea, early satiety and vomiting.

• Diabetes- as a large portion of pancreas removed, risk of developing diabetes.

• Malabsorption- pancreas makes digestive enzymes which help the body break

down food.

• Removal of all or part of the pancreas affects the amount of pancreatic

enzymes that are produced

• Affects the body’s ability to digest food, particularly fat and absorb vital

nutrients

Diet following Whipples

Post surgery common side effects include:

• Poor appetite

• Early satiety

• Nausea

• Abdominal discomfort e.g bloating, cramping, wind, flatulence, reflux

• Weight loss

• Diarrhoea/Steathorrea

Guidelines for eating and drinking:

• Start with clear fluids/liquids & progress to a low Residue diet.

• Eat small meals every 2–3 hours rather than three large meals.

• Have nourishing meals & snacks; include protein source at every meal e.g. meat, chicken, fish, dairy

products, eggs, tofu.

• Small sips of fluids between meals rather than with meals.

• Limit foods that produce wind (gas) and carbonated (gassy) drinks.

Diet following Whipples continued.

• Multivitamin supplement and/or a vitamin B12 and fat-soluble vitamin

supplement.

• Ensure correct dose of pancreatic enzyme is taken (Creon/Nutrizyme)

• Limit very fatty, greasy or fried foods if these cause discomfort, even when

taking adequate pancreatic enzymes.

• Nutritional supplements drinks, Fortisip compact/Fortijuce/Vital 1.5 are high in

energy and protein and have important vitamins and minerals. These may be

prescribed after surgery.

Pancreatic enzyme replacement.

Signs of PEI (pancreatic enzyme insufficiency) include:

• abdominal pain

• Bloating

• excessive wind

• diarrhoea or fatty bowel movements (stools) that are pale in colour, frothy, loose and difficult to flush

weight loss.

Who Needs Pancreatic Enzymes?

• Tumours in the pancreas

• Following pancreatic surgery

– Whipple Procedure

– Total Pancreatectomy

• Obstruction of pancreatic or biliary duct

Pancreatic enzyme replacement cont.

• PERT must be taken with all meals and snacks containing protein and fat.

• NB: Take with a cold drink.

• Meal higher in fat = more enzymes to be taken

• Divide doses throughout meal times

• Do not crush or chew

• Do not take with iron supplement

• Fruit juice, black tea and coffee do not need Enzymes

• What is my dose?- Dependent on numerous factors. Starting dose likely to increase

incrementally until symptoms controlled. Doctor/Dietitian will help adjust dosage.

• What if I take too many? – Constipation – Abdominal cramping – Nausea

Bile Acid Malabsorption (BAM)

• Bile is produced in the liver, stored in the gallbladder & released into small

intestine when food is eaten.

• 1. Breaks down & absorbs fats & vitamins

• 2. Removes waste products.

• 97% of bile acids are re-absorbed in the small intestine & returned to liver.

• If the final section of your small intestine becomes diseased/removed during

surgery/ damaged eg radiotherapy.

• Not enough of the bile salts are absorbed back into the body.

• This causes too much bile salt to reach your colon & causes fluid to be

pumped into the colon causing diarrhoea.

Causes of BAM

• Type 1:

Small intestine resections/ inflammation eg Crohn’s disease or cancer

treatment

• Type 2:

Primary BAM

• Type 3:

Secondary to GI diseases eg gallbladder removal, coeliac disease, chronic

pancreatitis, radiotherapy or small bowel bacteria overgrowth

• Diagnosis is done using a SeHCAT scan.

Symptoms of BAM

Diarrhoea:

• Can be frequent

• Pale & greasy and hard to flush away or may be unusually coloured.

• Smelly wind & erratic bowel movements

• Loss of weight due to excessive loss of bile salts

Stomach Problems:

• Bloating, cramping, abdominal pain and excessive wind

• Mimics IBS & can be misdiagnosed

• Also Vit B12 deficient, very tired and short of breath.

Treatment of BAM

Medications:

• Colestyramine and colestipol –only come in powder form. Can be unpalatable and

cause constipation if dose too high.

• Colesevelam –newer medication and comes in a tablet form.

• Codeine phosphate or Loperamide

Diet:

• Strict low fat diet (40g fat per day)

• Low fat product: 3g or less per 100g

• Reduce intake of fried, greasy foods, margarine, butter, mayo, baked goods, full fat

dairy products, processed meats.

Monitoring BAM

• Medications for BAM can lower levels of fat soluble vitamins

(A, D, E & K)

• Can also lead to increase in triglycerides.

• Recommend regular blood test to monitor above.

• Monitor for weight loss, stool frequency & consistency.

• Medication dose may need adjusting.

• May require supplementation of B12 and fat soluble vitamins.

Nutrition following Chemotherapy or

Radiotherapy

Managing your Symptoms

Poor appetite and/or weight loss

• Little & often approach. Aim for 6 small meals.

• Eat when your appetite is at its best.

• Try using small plates.

• Choose easy to eat foods eg soft foods rather than foods that require lots of chewing.

• Some steroids may assist in increasing your appetite eg. Dexamethasone/ metoclopramide.

• Eat foods high in protein & energy.

• Fortify meals: full fat milk/yogurt, butter, oil, margarine, mayonnaise, cheese, cream, skimmed

milk powder to full fat milk, packet soups, sauces, adding lentils/beans to soups and

casseroles.

• Snacks: cheese & crackers, toast with peanut butter/avo, muffins, full fat yogurt, milky coffees,

biscuits, small piece of cake, crisps, rice puddings, smoothies

• Nutritional supplements eg Fortisip, Ensure, Fortijuce.

Managing your symptoms cont.

Nausea

• Eat when you feel least nauseas & less likely to be sick

• Eat slowly- do not eat in a hurry

• Stay active

• Try not to lie down soon after eating

• Try dry & ‘bland’ food: toast, crackers, plain biscuits, pretzels, crisps, rice cakes

• Aim for small, frequent meals- every 2-3 hours.

• Ginger containing foods can reduce nausea: ginger tea, ginger ale, ginger biscuits

• Sips fluids throughout day rather than with your meal: water, lemonade, soda water & sip through

straw

• Peppermint tea can relax the stomach muscles & reduce nausea. Avoid strong coffee or tea.

• If you are vomiting, drink plenty of fluids; try sports drink & fruit dinks

• Avoid spicy, greasy, fatty or fried foods or foods with a strong smell eg fish/ blue cheese

• Ask your doctor about medications: cyclizine, metoclopramide, ondansetron.

Managing your symptoms cont.

Diarrhoea:

• Avoid fatty & spicy foods, fried foods, fatty meats and have oil/margarine in moderation

• Avoid alcohol and caffeine (can cause dehydration)

• Yogurt, cheese & custard may be better tolerated than milk as they contain less lactose.

• Avoid gas-producing foods & drinks eg. beans, carbonated drinks, beer, cabbage, spouts or

broccoli.

• Avoid very fibrous foods that may contribute to diarrhoea, eg fruits & vegetables with

hard/tough skins, seeds & pips

• Opt for low fibre foods eg white bread, white pasta, white rice

• Slowly increase fibre once diarrhoea has settled.

• Probiotic drinks can ease diarrhoea caused by antibiotics by replacing healthy bacteria.

Note, do not take if neutropenic.

• Drink 1.5-2L water/day (unless fluid restricted)

Summary

• Dietary advice/recommendations can be very confusing and overwhelming.

• If in doubt, speak to your doctor and ask for a referral to a dietitian.

• Follow nutrition guidelines which are evidence based and have had studies

done to prove its efficacy.

• Avoid diet fads/ advice that promises unrealistic results.

• Eat according to your symptom.

• opt for high protein and high calorie foods and snacks, and nutritional drinks

eg Ensure/Fortijuce/Fortisip Compact.

• Knowledge is Power.

Thank You.

Questions?

42-52 Nottingham Place

London W1U 5NY

www.theprincessgracehospital.co.uk

Liza.Strydom@hcahealthcare.co.uk